HISTORICAL DOCUMENT

Canadian Psychiatric Association

Association des psychiatres du Canada

Shared Mental Health Care in Canada

Nick Kates, FRCPC, Marilyn Craven, CCFP, Joan Bishop, FRCPC, Theresa Clinton, CCFP, Danny Kraftcheck, CCFP, Ken LeClaIr, FRCPC, John Leverette, FRCPC, Lynn Nash, CCFP, Ty Turner, FRCPC

This position paper was reviewed and delisted as an official position of the Canadian Psychiatric Association on September 17, 2010. It is being made available for historical purposes only. The paper was originally developed by the Joint Working Group of the Canadian Psychiatric Association and The College of Family Physicians of Canada and approved by the CPA’s Board of Directors on October 4, 1996.

EXECUTIVE SUMMARY Recognizing the need to respond to these issues, the College of Family Physicians of Canada (CFPC) and the The family physician already plays an extensive role Canadian Psychiatric Association (CPA) set up a working as a provider of mental health care in almost every commu- group to prepare a report that would highlight the advan- nity in Canada. In theory, the family physician and the tages of greater collaboration between family physicians psychiatrist are natural partners in the mental health care and psychiatrists and its benefits for both patients and system. While neither may be able to meet every need of providers and describe a range of practitioner behaviours, a patient with a mental disorder, each can offer comple- practices, and policies which could contribute to collabora- mentary services, which enables them to play a key role at tive mental health care. different stages of an episode of illness and the subsequent period of recovery. Too often, however, family physicians It was envisaged that such a report would encourage and psychiatrists fail to establish the collaborative working the implementation of shared mental health care in clinical relationships that would strengthen the role of the family practice and describe the ways in which it could enhance physician, enhance the consultative role of the psychiatrist, the current activities of family physicians and psychiatrists. and improve the quality of care their patients receive. It would also emphasize the need for appropriate prepara- tion of psychiatrists and family physicians to enable them The need to improve these relationships, a key step to work effectively in a shared care model. Although this towards a better-integrated and more efficient health care report limits its comments to shared care between psychi- system, becomes even more pressing in the current climate atrists and family physicians, many of the issues raised of rapid change in the organization of health care in Cana- are likely to apply to all mental health and primary care dian provinces. Almost every province is now involved providers. in reforming both its mental health care and primary care systems—often with minimal coordination of these The committee was aware of the wide variation in processes. In addition, many communities across the resource availability and organization of services across country are witnessing rapid and often sweeping realign- the country. It solicited input from psychiatrists and family ments of services, with an emphasis on shifting resources physicians, their professional associations and departments from hospital to community settings. of family medicine and psychiatry across Canada, and has drawn on a number of planning documents already prepared These changes are likely to accentuate the role of by provincial and national organizations. primary care as the cornerstone of the health care system and will be accompanied by significant changes in the In preparing this report, rather than presenting a single delivery of both secondary and tertiary care. This will model, we have outlined the key principles that should require new collaborative partnerships and models of guide collaborative activities between family physicians care delivery between family physicians and specialists, and psychiatrists. We then suggest 3 broad strategies— including psychiatrists. 1) improving communication; 2) building new linkages

© Copyright 1997, Canadian Psychiatric Association. This document may not be reproduced without written permission of the CPA. Members’ comments are welcome and will be referred to the appropriate CPA council or committee. Please address all correspondence and requests for copies to Canadian Psychiatric Association at 260-441 MacLaren Street, Ottawa ON, K2P 2H3; Tel: 613-234-2815; Fax: 613-234-9857; E-mail: [email protected] (reference 1997-38) or to The College of Family Physicians of Canada at 2630 Skymark Avenue, Mississuaga ON, L4W 5A4; Tel: 905-629-0900; Fax: 905-629-0893.

Distributed with The Canadian Journal of Psychiatry Vol 42, No 8 and The Canadian Family Physician Vol 43, October 1997 The Canadian Journal of Psychiatry and The Canadian Family Physician between family physicians and psychiatrists and psychiatric BACKGROUND services; and 3) integrating psychiatrists and psychiatric services within primary care settings—that can lead to the successful implementation of these principles and enhance Family physicians are in an excellent position to provide collaborative care. mental health care for their patients (1). Eighty-three percent of Canadians visit their family physician each year (2), and These strategies can be adapted to any community, the family physician is often the first point of contact for especially more isolated, underserved communities. Many an individual with a mental health problem (3). Over 50% of the suggestions outlined, particularly those for improving of people with mental disorders who receive mental health communication, require relatively small adjustments on the care receive it from their family physician, often without the part of practitioners but can lead to marked improvements involvement of any other provider (4). To be able to provide in working relationships. Shared mental health care is not optimal mental health care, however, the family physician an alternate style of practice but rather a component of care needs to be supported by and to work closely with psychia- that can become a valuable extension of the current clinical trists and psychiatric services (5–11). practices of the psychiatrist and family physician, broad- Four management patterns can be described for ening and enriching the care that each is able to offer. the mental health problems of patients with mental dis­- The audience for this report is not, however, restricted orders who are seen by their family physician. These are: to front-line practitioners. The successful implementa- 1) management by the family physician alone; 2) ongoing tion of models of shared mental health care also requires management by the family physician with additional advice changes within other parts of the health care system and or support from a psychiatrist or other mental health care the active support of professional associations of family provider; 3) referral to a psychiatrist or psychiatric service physicians and psychiatrists, of academic departments of for a consultation; and 4) referral to a psychiatrist or psychi- family medicine and psychiatry, and of bodies responsible atric service for continuing care. In each of these scenarios, for health service planning and the setting of policy at local, a positive working relationship with a psychiatrist or mental provincial, and national levels. health service can assist the family physician in detecting and treating a problem and enhance the quality of care a It also challenges policy makers and planners to find patient receives. ways to integrate the concurrent reforms of primary care and mental health taking place in each Canadian province Too often, however, family physicians and psychiatrists and to address the policy and planning implications of fail to establish the collaborative working relationships that shared mental health care. would strengthen the role of the family physician, enhance the consultative role of the psychiatrist, and improve the A number of collaborative projects have already been quality of care their patients receive (11,12). This is unfor- established across Canada, and more are likely to follow. As tunate because family physicians and psychiatrists would new projects are set up, it is important that they be evaluated make natural partners in the mental health care system, to enable us to learn about the benefits and any possible offering complementary services. Neither may be able to drawbacks of shared mental health care and to use the find- meet every need of a patient with a mental disorder, but ings to enhance future projects. each can play a key role at different stages of an episode of The mandate of the CFPC-CPA committee was to illness and the subsequent period of recovery. achieve consensus on these issues among psychiatrists and Collaborative care between family physicians and family physicians. Consequently, this report does not address psychiatrists is a critical step toward improving the mental similar issues pertaining to other professional groups. Many health care received by Canadians. It enriches the care each individuals from a variety of professional backgrounds play can offer and facilitates a biopsychosocial approach to a key roles in delivering mental health care in both primary comprehensive range of mental health problems and dis- care and mental health service settings. The principles and orders, enhancing the well-being of individuals and com- practices outlined in this report, however, may be appli- munities. It also encourages a more efficient and effective use cable to interactions between all primary care providers and of increasingly limited resources and can heighten the skills mental health service personnel. Further discussion among and satisfaction of family physicians and psychiatrists alike. these groups of the possibilities and implications of shared mental health care is clearly desirable. 1.1 Purposes of this Document The successful implementation of shared mental health care is likely to strengthen communication, collaboration, The CFPC and the CPA recognized the importance of and mutual support between psychiatrists and family physi- collaborative care and set up a working group to prepare cians and lead to improved access to psychiatric consulta- a report that would: 1) highlight the advantages of greater tion and treatment care for Canadians. It will also facilitate collaboration between family physicians and psychiatrists a more efficient use of available resources and lead to a less and its benefits for both patients and providers; 2) describe fragmented, better-integrated health care system. a range of practitioner behaviours, practices, and policies

2 Shared Mental Health Care in Canada which can contribute to collaborative mental health care; THE CURRENT SITUATION 3) encourage the implementation of shared mental health care in clinical practice; 4) emphasize the need for appro- 2.1 Mental Health Problems in Family Medicine priate preparation of psychiatrists and family physicians i. The Burden of Illness to enable them to work effectively in a shared care model; and 5) encourage policy makers and planners to find ways Approximately a third of all family practice patients to integrate the concurrent reforms of primary care and have identifiable mental health problems (13–15), and mental health taking place in each Canadian province and 25% of all patients who visit their family physician have to address the policy and planning implications of shared a diagnosable mental disorder (16–18). These figures may mental health care. be even higher for teenagers (3) and the elderly (19). The family physician is the first and often the only contact with It is anticipated that the implementation of the recom-­­ a mental health care provider for individuals with mental mendations in this document will lead to a strengthening of health problems or psychiatric disorders. These problems links between psychiatrists and family physicians in both are often enduring, and many are severe and disabling (20). clinical practice and training which will benefit providers, One American study found depression to be as disabling a patients and the health system as a whole. Some of the disease as 8 common physical disorders, such as cardiovas- potential benefits are as follows: cular disease or rheumatoid arthritis, in terms of the cost to the individual and the community (21). For Patients • enhanced quality of mental health care received ii. Comorbid Problems • improved access to psychiatric consultation when Many individuals with physical illnesses treated in required primary care experience emotional symptoms, either as a part of or in reaction to the presence of the medical condi- • improved access to psychiatric services when required tion. Effective treatment of these symptoms can reduce morbidity and decrease utilization of other health services For Providers (22–25). The family physician is also in a good position to • increased skill and comfort on the part of family physi- treat the medical problems of individuals with a psychiatric cians in managing mental health problems disorder, which have a higher risk of not being treated, to • increased effectiveness on the part of psychiatrists as recognize comorbid drug or alcohol dependency, and to consultants and supports to family physicians initiate treatment or referral at an early stage of an episode of illness. • mutual support when managing complex mental health problems. 2.2 The Role of the Family Physician For the Health Care System Ninety-seven percent of Canadians have a family • a more efficient and effective use of available resources physician, and 83% will visit their family physician during • models that will enhance the mental health care the course of a year (2). A recent study of the practices provided for individuals living in more isolated of family physicians in each of Ontario’s health planning communities regions (12) confirmed that family physicians spend a large • elimination of some of the barriers that prevent better proportion of their time diagnosing and treating individuals integration of mental health and primary care reform who have emotional or psychiatric problems. In addition, in many parts of the country, family physicians also treat • opportunities for collaborative projects that lead to individuals with mental health problems during inpatient the prevention or early detection of mental health admissions. The family physicians in this study empha- problems. sized the broad range of mental health problems they see, The mandate of the CFPC-CPA committee was to the high prevalence of these problems, the frequent overlap achieve consensus on these issues among psychiatrists of physical and emotional symptoms, and the importance and family physicians. For that reason, this document does of the family physician as a key provider of mental health not address issues pertaining to other professional groups. care. Family physicians indicated they dealt with a large Many other individuals from a variety of professional back- number of mental health problems in individuals of all ages, grounds play key roles in delivering mental health care in including many with serious mental illnesses, and they both primary care and mental health services. The principles stressed the importance of and need for a well-integrated biopsychosocial approach to all aspects of a patient’s care. and practices outlined in this report, however, may be appli- cable to interactions between all primary care providers and The family physician has a number of natural advan- mental health service personnel. Further discussion among tages as a provider of mental health care. He or she has a these groups of the possibilities and implications of shared continuing relationship with the patient (48% of Canadians mental health care is clearly desirable. have had the same family physician for at least 10 years [2]),

3 The Canadian Journal of Psychiatry and The Canadian Family Physician has knowledge of the patient’s family and of the physical These plans have a number of common goals including and social environment in which the patient lives, and has the more efficient use of resources, better coordination of an understanding of coexisting general medical problems services, and a shift to more community-based care. Most and available community resources, including other health mental health reform planning documents overlook the role providers who are involved with the patient (for example, of the family physician as a key mental health care provider other medical specialists or community nursing agencies). and provide minimal commentary on the role of the psychi- These advantages put the family physician in an excel- atrist within the reformed mental health system. These lent position to identify and treat mental health problems oversights are significant and potentially costly. Without a at an early stage, prevent relapse after an episode has been clear understanding of the roles of the psychiatrist and the successfully treated, assist individuals and families in family physician, mental health reform is likely to result in maintaining good mental health, coordinate the health and a poorly coordinated system, fragmented care, and less effi- mental health services an individual may require, detect and cient services. treat the medical problems of individuals with mental dis- orders and encourage healthy lifestyle choices, and provide ii. Primary Care Reform support and information for the families of individuals with Canadian provinces are also in the midst of reforming a serious mental or physical illness. primary care services, a process that has been catalyzed by a joint statement prepared by the ministers of health of the 2.3 The Role of the Psychiatrist provinces and territories (27) which envisages primary care as the cornerstone of the health care system, consistent with Increasingly, psychiatrists are being asked to func- the vision for health care espoused by the World Health tion as consultants and as members of multidisciplinary Organization (8). teams. They are able to provide comprehensive biopsycho- This renewed emphasis on primary care makes the need social assessments and formulations, play an active role in for new models of collaboration between family physicians developing treatment plans, especially regarding the use and specialists, highlighted in a joint document on consulta- of psychotropic medication, provide ongoing treatment or tive care produced by the CFPC and the Royal College of rehabilitation where appropriate, assist family physicians Physicians and Surgeons of Canada (RCPSC) in 1993, even and other medical specialists in the management of indi- more pressing (28). It also opens up many possible avenues viduals with comorbid medical disorders, and facilitate for better integration of specialized services (including referrals to more specialized psychiatric services (9,10,26). psychiatric services) within primary care settings (29). These new roles will also demand greater integration within the medical community and an enhancement of medical The lack of coordination between primary care reform and diagnostic skills. Another important activity for the and mental health reform—one of which highlights the role psychiatrist is providing indirect (patient not seen) consul- of the family physician as a key mental health care provider tation to other providers of mental health care that may be (primary care reform), the other which virtually ignores patient-, staff-, or program-centred (26). this role (mental health reform)—needs to be addressed. A more collaborative planning process is clearly required if One emerging challenge facing psychiatry is a changing the resulting health care system is to be coherent, efficient, pattern of consultation to other medical specialties. Shorter and cost-effective. lengths of stay in medical and surgical units in general hospitals are leading to a greater demand for outpatient iii. Long-Term Care Reform rather than inpatient consultation. This trend makes it more likely that the psychiatrist will be consulting to the family Individuals requiring long-term care, many of whom physician as well as or instead of another medical specialist. are elderly, often present with complex medical and This focus on consultation and collaboration with referral psychiatric needs. Although many long-term care plan- sources also highlights the potential of the psychiatrist as an ning processes have overlooked the need for physical and educator (10,26). medical treatments, the care of an older individual with comorbid medical and psychiatric problems represents the While these activities should complement and rein- quintessential situation where the psychiatrist and family force the mental health care activities family physicians physician need to be able to work collaboratively. can offer, most psychiatrists have little contact with family physicians, and few spend any time working directly with family physicians. 2.5 Service Realignments and Cost Constraints Reductions in funding for hospital services and a shift 2.4 Health Care System Reform in resources from hospitals to the community are having an impact on both family physicians and psychiatrists. Many i. Mental Health Reform procedures and treatments that used to be conducted in Over the last 5 years, most Canadian provinces have hospitals or clinics are now being “off-loaded” to family embarked upon reform of their mental health systems. physicians, who are being expected to take on additional

4 Shared Mental Health Care in Canada patient care responsibilities, often with few additional their family physician, and less than 10% of individuals resources or supports. Reduced access to inpatient psychi- with an addiction problem would talk about the problem atric beds and pressures to shorten lengths of stay have unless specifically asked (30). There is clearly a need for also resulted in psychiatric clinics and family physicians innovative public education approaches that will increase managing individuals who have more acute and less stable the likelihood that such problems will be brought to the mental health problems. family physician’s attention (31,32). The expanding role of the family physician in deliv- ering mental health care can be assisted by rapid access to specialized services and supports that complement and PROBLEMS IN THE PRESENT RELATIONSHIP reinforce the care the family physician provides. At times of BETWEEN PSYCHIATRY AND FAMILY cost constraint, collaboration could lead to better outcomes MEDICINE and quality of life for consumers, a more efficient use of resources and increased satisfaction for providers. Recent studies of family physicians in Canada and other jurisdictions have found similar and frequently 2.6 Underserved Domains occurring problems in the relationship between psychiatry and family medicine (10,12,33,34). Some of these reflect Most provinces have identified populations that do broader systems issues, such as the pace and demands of not receive adequate mental health care. These include primary care, methods of remuneration, and poor coordina- both geographic areas, such as isolated communities, and tion of planning within provincial ministries of health. specific target populations like the elderly or certain cultural groups. More specific problems that have been identified include a lack of communication between psychiatrists i. Underserved Communities and family physicians caring for the same individual, diffi- culty on the part of family physicians in accessing consul- Most Canadian provinces face difficulties in providing tation and treatment services for their patients, and a lack specialized health services to individuals living in more of mutual respect and support for the contributions that isolated communities. While recruitment of specialists to providers from different disciplines can make in delivering work in these areas will remain an important component of any overall solution, there is also a need to develop alter- mental health care (11,12,35,36). These problems can be nate models of care that are based in primary care and use summarized under 3 general headings: difficulty with psychiatric resources as efficiently as possible, providing access, poor communication, and lack of personal contact. direct and indirect consultation, teaching, and skill develop- ment as well as ongoing care. 3.1 Difficulty with Access ii. Underserved Populations Family physicians are frequently frustrated by the diffi- While a number of groups in our communities under- culties they encounter when trying to access psychiatric utilize potentially beneficial mental health services, consultative or treatment services and by the seemingly many of these individuals receive general health services unnecessary obstacles in referral procedures, especially from family physicians. Although family physicians are when they perceive the problem to be urgent. Psychiatric in an excellent position to provide mental health care to services are often perceived as being not user-friendly, with these individuals and to link them with other psychiatric arbitrary exclusion criteria that make apparently artificial and community services, they frequently have difficulty and inconsistent divisions between psychiatric and psycho- accessing psychiatric backup, advice, or consultation. As social problems and with catchmenting boundaries that a result, many individuals in these groups fail to receive may conflict with a family physician’s hospital affiliation. needed services. Family physicians have identified that most of these prob- lems do not occur to the same degree with other medical 2.7 Use of Mental Health Services in Primary Care and surgical specialties.

The health care system encourages individuals to see By the same token, psychiatrists and other mental their family physician as the first point of contact (3), some- health care providers are sometimes faced with a reluctance thing that will be reinforced if rostering is introduced on a on the part of the family physician to take responsibility for large scale (27). Most Canadians already have an enduring the continuing mental health care of a patient once an acute relationship with a single family physician, although they episode has been stabilized. The reasons for such reluctance may not always consider seeking mental health care from may be multiple, including the physician’s level of comfort their family physician. A number of studies, including the with, interest in, and knowledge of such problems, a lack recent Edmonton Household Survey, found that only 50% of support from the psychiatric system, and financial dis- of individuals who were depressed would raise this with incentives.

5 The Canadian Journal of Psychiatry and The Canadian Family Physician

3.2 Problems in Communication responsibilities for both family physician and psychiatrist, are required to promote an integrated and holistic approach There are several frequently cited problems in commu- to physical and mental health problems and ensure greater nication between family medicine and psychiatry. First, continuity of care. This can be achieved if the psychiatrist family physicians are often not informed about the progress and family physician work collaboratively to share the of a patient after he or she has been assessed by a psychia- delivery of mental health care (37–49). trist or psychiatric service or about treatment changes, secondary referrals to other specialists, or discharge plans. Shared care is a process of collaboration between Psychiatric services do not always consider the trans- the family physician and the psychiatrist that enables the mittal of this information to be a routine and essential responsibilities of care to be apportioned according to the part of their management. In a similar vein, at the time treatment needs of the patient at different points in time of referral, psychiatrists and psychiatric services are not in the course of a mental health problem and the respec- always provided with sufficient information by the family tive skills of the family physician and psychiatrist. Rather physician to make appropriate decisions about treatment than being seen as a separate style of practice, shared care goals and initial management. Third, family physicians are can become a valuable extension of the clinical practice often unclear about the inclusion and exclusion criteria and of psychiatrists and family physicians and an integral part intake policies of psychiatric services. Fourth, goals and of the treatment of any individual with a mental disorder expectations for a referral are not always discussed and whenever a family physician requires additional input from clarified when a referral is made. This can create confu- a psychiatrist or psychiatric service. sion as to which provider is responsible for which aspects Shared care covers a broad spectrum of collaborative of a patient’s care. Fifth, there is often a delay on the part treatment possibilities, and no single model or approach of psychiatrists or psychiatric services in providing assess- will be applicable in every community or situation. At the ment and discharge notes to referring family physicians. A very least, it involves clear, helpful, 2-way communication sixth problem of communication is that family physicians between the family physician and psychiatrist or psychiatric and psychiatrists are often difficult to reach by phone, espe- service. At the other end of the spectrum, it may involve cially for nonphysician health care providers. psychiatrists and/or other mental health workers providing Because many psychiatric services are organized consultation and treatment in the family physician’s office into teams in which psychiatrists and other providers and developing collaborative management plans with the work together, the family physician may be dealing with family physician. Functions that lend themselves well to 3 or 4 individuals who are involved with a single patient. shared care include early detection and the initiation of This too can fragment communication. In addition, family treatment, ongoing monitoring, crisis intervention, relapse physicians may not understand their responsibilities under prevention, and mental health education. Shared care mental health legislation and the limits such legislation can should lead to improved patient outcomes and quality of impose. These can be a source of great frustration. Finally, life; a more efficient use of resources; optimal use of the in certain situations, confidentiality issues can make it diffi- time and skills of family physicians, psychiatrists, and other cult for providers to exchange information. providers; improvement in the ability of family physicians to access timely and appropriate psychiatric consultation and backup; and enhanced morale and reduced frustration 3.3 Lack of Personal Contact on the part of providers.

Family physicians often have never met the psychiatrist 4.1 Principles to Guide Shared Mental Health Care to whom they are referring and do not come into contact with him or her on a regular basis through hospital or other Shared mental health care should be based on a consis- activities. This lack of personal contact makes it less likely tent set of principles. that mutual cases can be discussed and works against family • Family physicians and psychiatrists are part of a single physicians and psychiatrists learning about each other’s mental health care delivery system. skills, strengths, and interests. In the worst extreme, the relationship between psychiatry and family medicine is • The family physician has an enduring relationship with characterized by stereotypic misconceptions and a lack of a patient that the psychiatrist should aim to support and respect for the role that the other discipline can and does strengthen. play in providing mental health care. • No single provider can be expected to have the time and skills to provide all the necessary care a patient SHARED MENTAL HEALTH CARE may require. • Professional relationships must be based upon mutual These findings suggest a need for a significant reap- respect and trust. praisal of the relationship between family physicians and psychiatrists. Alternative models of collaboration that are • Roles and activities of different providers should be more collegial and interactive, with clearly defined roles and defined, coordinated, complementary, and responsive

6 Shared Mental Health Care in Canada

to the changing needs of patients, their families, and 03. Psychiatrists and psychiatric services can improve other caregivers, as well as to resource availability. information transfer by contacting the family physi- cian whenever a patient is referred to a mental health • The patient must be an active participant in this process, service, significant treatment changes take place, or understanding that both the family physician and psychi- a patient is about to be discharged to the care of the atrist will remain involved in his or her care and knowing family physician. who to contact when a particular problem arises. 04. Psychiatrists and family physicians can work together • Models of shared care should be sensitive to the context to determine what information a psychiatrist or the in which such care takes place. Some of the contextual psychiatric service requires at the time of referral variables that need to be taken into consideration include and data a family physician requires in a discharge or the socioeconomic setting and demographics of the consultation note. patient population; the mental health care skills, interest, and comfort level of the family physician; the consulta- 05. Family physicians should be contacted and involved at tion skills, interest, and comfort level of the psychiatrist; an early stage in developing discharge plans. the level of support available from local mental health 06. Psychiatrists and psychiatric services can prepare brief services and their readiness to take patients identified as (one-page) summaries of treatment and discharge needing additional or more intensive psychiatric care; plans to be given to the family physician at the time of the availability of specialist psychiatric backup; and the discharge. availability of local nonmedical mental health resources. 07. Similarly, succinct information sheets for family physi- cians on the management of specific problems or medi- 4.2 Strategies for Implementing Shared Mental cations can be prepared by psychiatrists to accompany Health Care discharge notes. 08. Because family physicians continue to provide phys- The successful implementation of shared mental health ical health care after a patient has been referred to a care can bring benefits to family physicians, psychiatrists, psychiatrist or psychiatric service, psychiatrists need to patients, and the health care system as a whole (50,51). Three ensure that the family physician is informed promptly different but complementary strategies can be employed to of any pharmacological intervention. Similarly, family support and enhance shared mental health care. The choice physicians need to inform the psychiatrist or psychi- of strategy will vary according to local needs, resource atric service of any drug treatment that may affect the availability, and other organizational factors. Many of the patient’s emotional health or interact with a psycho- ideas outlined below have already been successfully imple- tropic medication. This exchange can be facilitated by mented, albeit in a limited manner, by practitioners, services, treatment cards carried by the patient to all appoint- and academic departments in different parts of the country. ments, which detail any changes in medication or treat- The goals of these strategies are 1) to improve communica- tion in the working relationship between a psychiatrist or ments. psychiatric service and local family physicians, 2) to estab- 09. Family physicians and psychiatrists should provide lish liaison relationships between psychiatrists or psychi- each other with the number of their private (back) tele- atric services and one or more local family physicians, 3) to phone line and fax number to make communication bring psychiatrists and/or other mental health providers into easier. the family physician’s office. 10. Family physicians should be accessible to calls from nonphysicians who are working in a psychiatric service Strategy 1: Ways to Improve Communication and treating or managing their patients. Nonphysician For the most part, these approaches require minimal providers should, however, respect the desire of the time commitment or additional resources and are applicable family physician to discuss pharmacological issues in almost every clinical setting or community. Improved directly with a psychiatrist. communication is central to effective shared care. 11. Psychiatric services and psychiatrists can provide 01. For every person referred to a psychiatrist or psychi- family physicians with up-to-date information on atric service, the respective roles and responsibilities mental health services available within their commu- of the family physician and the psychiatrist or mental nity. health provider should be made explicit, including 12. Psychiatric services should solicit input from family the prescription of medication. The patient should be physicians when planning or evaluating mental health informed of these roles and responsibilities. services. This can include ongoing surveys of unmet 02. Family physicians and psychiatrists can get to know service needs as perceived by family physicians. each other by arranging shared clinical or educational 13. Psychiatric services and family practices should make rounds or one-to-one meetings to discuss difficult any administrative adjustments necessary to facilitate cases. and support better communication.

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Strategy 2: Establish Family Medicine–Psychiatry physician in conjunction with a psychiatrist on a Liaison Linkages regular basis to ensure that these individuals are seen The following approaches involve personal contacts routinely and that their treatment needs are addressed. between psychiatrists and family physicians to develop linkages or activities that enhance communication and Strategy 3: Encourage Visits by Psychiatrists to collaboration and provide mutual support. These can also Family Physicians’ Offices have an important educational component. In some situations, there may be opportunities for a 01. Formal links between a psychiatrist and one or more psychiatrist to spend part of his or her week working within family physicians to provide advice and backup by a family physician’s office. An essential component of this phone for patients the family physician is seeing. strategy is the ongoing contact between psychiatrist and These links can be established with family physi- family physician. There are a number of ways to achieve cians in general practice and also with physicians who such contact: are caring for a large number of patients who share a 01. The psychiatrist visits the family physician’s office common predicament such as AIDS patients, members on one or more occasions to provide follow-up for a of cultural minorities, or residents of local shelters. recently discharged patient. This may involve a review of plans and progress or a meeting together with 02. Regular meetings to discuss cases. These provide a the patient. It may occur at a prearranged time after forum for family physicians to meet with a psychiatrist discharge or if a new problem arises. singly or in groups to discuss complex or challenging cases and receive feedback, advice, and support. These 02. The psychiatrist visits a family physician’s office peri- meetings can also enable the psychiatrist to distribute odically to provide consultations or review specific and review relevant educational materials. problems on an as-needed basis. 03. The development of a model similar to the obstetric 03. The psychiatrist visits the family physician’s office on shared care model employed in some parts of a regular basis. Visits may be as brief as an hour or as the country. This would identify levels of risk or long as a full day. Such visits could involve the assess- complexity for each patient with guidelines as to the ment of new patients, follow-up of patients previously roles and responsibilities of the psychiatrist or psychi- seen, a review of patients or problems the family physi- atric service and the family physician. cian is managing, and focused educational sessions on topics of the family physician’s choosing. The 04. The development of rapid reassessment protocols for psychiatrist and family physician work collaboratively, patients who have been seen previously by a psychia- sometimes seeing patients together, and discuss their trist or psychiatric service. If a family physician is respective responsibilities for the patients for whom providing ongoing care for a patient discharged from a they are caring. psychiatric service, that psychiatrist or service should offer a rapid reassessment when this is requested by the 04. The psychiatrist functions as a member of a mental family physician. health team located in the family physician’s office. While the activities of the team may be similar to 05. The provision by psychiatrists or psychiatric services those described above for the visiting psychiatrist, the of educational materials such as screening instruments, psychiatrist can play a number of additional roles: useful articles, or treatment protocols to local family physicians that may assist in the management of their i. The psychiatrist provides backup or consultation patients. This can be followed up by a telephone call to to the family physician, mental health workers (for answer any questions the family physician may have example, social workers, nurses), and any other concerning the use of the materials. health workers (for example, a community nurse) attached to that practice. This can be done by phone 06. The availability of psychiatrists to provide support, or by regular visits to the family physician’s office. advice, or a consultation to family physicians who manage their own patients during an inpatient admis- ii. The psychiatrist visits the family physician’s office sion to hospital. on a regular basis to work collaboratively with the family physician and mental health worker(s) 07. The organization of periodic joint hospital rounds for seeing patients as well as to be available for consul- psychiatrists and family physicians on topics of mutual tation and backup. interest. 5. The psychiatrist provides educational interventions 08. The development by family physicians of registers of within the family physician’s office. Working in the patients in their practice who are at risk of developing family physician’s office opens new avenues for inno- specific psychiatric problems, for example, individuals vative approaches to continuing education with family who have a psychotic illness or who are elderly and physicians. This can be done by one-to-one sessions isolated. These lists can be reviewed by the family with a single family physician or educational sessions

8 Shared Mental Health Care in Canada

with a group of family physicians working in that prac- 01. A visiting psychiatric consultant who periodically tice on topics of the family physician’s choosing. spends a defined amount of time in the community (for example, a day every 4 to 8 weeks), providing 4.3 Additional Steps Required to Support These consultation and follow-up as needed. When visiting Strategies a community, the psychiatrist needs to work closely To support the specific strategies outlined above, the and collaboratively with the family physician to following steps need to be taken. ensure continuity of care. Time can also be spent reviewing cases and discussing problems with cases 01. Psychiatric services need to make entry into the the family physician is handling and in educational “formal” mental health system as efficient as possible. sessions for local providers. The psychiatrist will also This means dismantling unnecessary administrative be available for telephone consultation in between obstacles and giving a clear message that a referral is visits. welcome and assistance will be forthcoming. This can also be combined with case review groups, 02. Family physicians need to be willing to provide ongoing in which family physicians meet as a group with the care for many individuals with mental illness, knowing visiting psychiatrist to discuss and monitor the pro- that appropriate support and input from mental health gress of selected cases, some of whom the psychia- services will be available if requested. trist may be familiar with from a previous visit. These groups could also meet in between visits as, a peer- 03. Two-way communication between care providers must support group. take place on a regular basis. 02. The availability of a psychiatrist working in a more 04. Partners in shared care should establish personal populated centre to provide consultations or advice contact with each other and be able to provide each by phone to family physicians in more isolated other with mutual support and information on the communities. management of patients with mental health problems. 03. Utilization of newer technologies, such as video confer- 05. The location where care is delivered can vary according encing, to provide clinical consultation and educational to the needs of the patient. input. 06. There needs to be ongoing evaluation of the impact and 04. Educational sessions and workshops organized by a outcomes of shared mental health care, with activities visiting psychiatrist on practical management issues, being adjusted according to findings. with opportunities for follow-up after the session (telephone discussions). 07. The family physician(s) and psychiatrist need to meet before any collaborative activity is initiated to clarify 05. Ongoing educational forums involving psychiatrists their common agenda, goals, and expectations and to and family physicians organized through the Internet. determine how the success of any such approach will 06. Further training in residency programs for family be measured. Ongoing review meetings need to take physicians from isolated communities to enable them place periodically. to develop additional skills in managing mental health 08. The psychiatrist and family physician must clarify problems. respective roles and responsibilities in every situation 07. The development of self-administered computerized where care is being shared. educational packages.

OTHER IMPLICATIONS OF SHARED 5.2 Implications for Academic Departments of MENTAL HEALTH CARE Psychiatry and Family Medicine Departments of psychiatry and family medicine should 5.1 Implications for Underserved Communities see primary care psychiatry or shared mental health care as a core area of clinical activity, emphasizing and supporting In many of Canada’s more isolated communities, where its importance in educational programs. a psychiatrist is not available on a permanent basis, the family physician usually assumes a more prominent role in delivering mental health care. Shared care offers a number Training of possibilities for reinforcing and supporting the role of the Many of the problems in the relationship between family physician and using scarce resources as efficiently as psychiatrists and family physicians reflect the fact that little possible. Most provinces have already implemented some attention is paid to collaborative models of practice in resi- of these ideas, but the key to their successful implementa- dency training programs. If significant changes are to be tion is adherence to the principles outlined earlier. In under- wrought in clinical practice, they need to begin with appro- served communities shared care may involve the following priate educational experiences that prepare trainees for the elements. realities of collaborative care.

9 The Canadian Journal of Psychiatry and The Canadian Family Physician

For psychiatry residents, training programs should pro- seeking to evaluate models of shared mental health care and vide 1) contacts with family physicians and family medicine their impact on local health systems. residents in a variety of settings throughout their training. These can be a part of rotations such as outpatient, child, Interdepartment Collaboration or geriatric psychiatry; 2) an understanding of the role the Departments of psychiatry and family medicine should family physician plays in managing mental health problems establish closer ties. These could enhance and support and the kinds of problems the family physician manages; clinical activities, enrich teaching programs, and generate 3) practical skills in primary care consultation; 4) exposure collaborative research projects. One further area of poten- to role models who are experienced in primary care consulta- tial collaboration would be for academic departments to tion and shared mental health care; and 5) practical experi- find ways of initiating and supporting outreach activities by ences and supervision in working within models of shared psychiatrists to underserved communities. mental health care. The ability to offer satisfactory training experiences in primary care psychiatry may become an accreditation 5.3 Implications for Continuing Education requirement of residency programs. National standards One of the important benefits of shared care is the should be developed for satisfactory training in these areas opportunity for participants to increase their skills and within psychiatry residency programs by the RCPSC, in knowledge. Collaboration between psychiatrists and family conjunction with the CPA and CFPC. Such training would physicians offers many exciting educational possibilities. be consistent with the recently established CanMEDS These include: 2000 program established by the RCPSC, which aims to prepare residents to meet the future health care needs of 01. Brief, focused, case-based educational presenta- Canadians (52). Roles identified for specialists that should tions and discussions. This includes regular meetings be highlighted in residency training programs include of groups of family physicians with a psychiatrist to those of medical expert, communicator and collaborator. review cases. For family medicine residents, training programs 02. Brief one-to-one or small-group educational activities should provide 1) contacts with psychiatrists and psychi- within the family physician’s office, if a psychiatrist is atry residents in a variety of settings throughout their visiting on a regular basis. training; 2) training on how to make optimal use of a 03. Opportunities for psychiatrists to update their know- psychiatric consultation or a psychiatrist who visits their ledge of general medical conditions and their treat- office; 3) an understanding of the principles of shared ment. This is consistent with the need for psychiatrists mental health care and ways in which psychiatrists can to reinforce their medical skills to be able to work assist family physicians; 4) exposure to role models optimally as consultants to other physicians. who can work collaboratively with psychiatrists; and 5) practical experiences and supervision in working within 04. The use of new educational technologies (computer models of shared mental health care. educational programs, Internet linkages) reinforced by regular contact between family physicians and psychi- In undergraduate medical programs, the principles atrists. of shared care between family physicians and all medical and surgical specialties, as well as ways in which such 05. The application of evaluative data on models of collab- approaches can be implemented, should become a part orative care within practices and clinics. of the undergraduate curriculum, forming an integral part 06. Continuing education credits for nontraditional educa- of any teaching that addresses the physician’s roles and tional activities within the family physician’s office. responsibilities, continuity of care, and the most efficient use of resources. 5.4 Possible Barriers to Implementation Finally, for postresidency training, departments could establish fellowships to provide additional training in this Despite the many benefits of shared mental health care, area. there are a number of possible obstacles that need to be All of these training programs could be enhanced if overcome. These include: departments can recruit faculty with expertise in shared • the current fragmentation of planning between primary mental health care who could play active roles as supervi- care and mental health services at both provincial and sors and role models and provide leadership in the develop- local levels in most Canadian provinces ment of academic programs in aspects of shared care. • lack of recognition of the role of the physician in Research mental health reform and health care planning Academic departments could play central roles in initi- • increasing patient loads faced by many family physi- ating and supporting research projects and grant proposals cians and psychiatrists

10 Shared Mental Health Care in Canada

• insufficient numbers of psychiatrists in certain parts of could include the provision of alternate methods of the country remuneration for psychiatrists, such as sessional fees; • a lack of necessary skills in consultation to primary changes in provincial fee schedules to cover services care physicians by some psychiatrists rendered by psychiatrists and family physicians that do not involve direct (the patient is seen) patient care; • insufficient emphasis on primary care consultation in alternate funding arrangements for primary care, such psychiatry residencies issues of confidentiality that as global budgets or capitation, which could fund may limit physician-to-physician communication services provided by psychiatrists; the secondment of • a lack of clarity concerning the assignation of medico- mental health staff from clinics to family physician’s legal responsibility in shared mental health care offices; or incentives to encourage family physicians • negative attitudes on the part of some family physicians to spend necessary amounts of time with individuals and psychiatrists toward the contributions the other can with complex psychiatric disorders. make 07. Regional planning authorities consider the poten- • problems with current systems of remuneration, which tial role that shared mental health care could play in do not cover indirect (nonpatient contact) services such building continuous service networks. as case discussions, educational input, or travel to and 08. Provincial planners continue to explore the possibili- from a family physician’s office. ties of shared care approaches as part of the solution There appears to be a consensus among psychiatrists to the shortage of psychiatrists in isolated areas. and family physicians across the country that this last point 09. Academic departments of psychiatry and family may be the most significant barrier to the successful imple- medicine review their curricula to ensure that resi- mentation of shared care and that alternate methods of dents receive appropriate preparation to enable them remuneration will be required to support these activities. to work collaboratively after graduation. 10. Academic departments of psychiatry and family medicine consider the possibility of emphasizing SYSTEM-WIDE CHANGES REQUIRED TO linkages between family physicians and psychiatrists SUPPORT SHARED CARE as a focus of academic excellence, offering special- Changes at the provider level need to be reinforced by ized training for residents and fellows and supporting adjustments within regional and provincial mental health collaborative investigative projects. systems and in family medicine and psychiatry profes- 11. The CPA and CFPC establish an ad hoc conjoint sional associations. We would recommend the following: working group to oversee the implementation of the 01. Family physicians and psychiatrists look at ways of recommendations of this report and to address other establishing closer ties, consistent with the guidelines related issues. of this document. 12. The CPA and CFPC encourage provincial colleges 02. Within communities, networks of family physicians of family physicians and psychiatric associations to and psychiatrists who are interested in collaborative establish joint provincial working groups to facilitate care be established. Participants would be able to better coordination of planning, research, and educa- exchange ideas, share experiences, and advocate for tional initiatives at provincial levels. the development of pilot projects. 13. Provincial governments look at ways to begin to integrate planning processes for mental health and 03. Funding and resources be made available for demon- primary care reform. stration projects of shared mental health care, which will be evaluated. Conclusion 04. Evaluation protocols be developed to assess the impact of shared care on patient outcomes, service In a period of rapid change in the organization of utilization, costs of health and mental health care health service across Canada, the concepts that underlie delivery, and community well-being. These could be shared mental health care between psychiatrists and developed by one or more centres and made available family physicians are straightforward and timely. If on a province or nationwide basis. family physicians and psychiatrists can work together, 05. A national clearinghouse be established to compile they can enhance continuity of care, strengthen the descriptions of programs and useful materials (such continuing relationship a family physician has with as discharge forms or educational packages) that his or her patient, and increase the accessibility of would be available to all interested practitioners psychiatric care. across Canada. Shared care is not an alternate style of practice, but 06. New funding approaches be developed to support the rather a component of health care that can be easily inte- implementation of some of these strategies. Options grated with other treatments employed by psychiatrists

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